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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880723
Report Date: 11/30/2022
Date Signed: 11/30/2022 11:28:19 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/12/2021 and conducted by Evaluator Melody Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20211012101603
FACILITY NAME:ATIENZA RESIDENTIAL CAREFACILITY NUMBER:
331880723
ADMINISTRATOR:ARMSTRONG, CAROLINEFACILITY TYPE:
740
ADDRESS:1328 GALAXY DRTELEPHONE:
(909) 792-3835
CITY:BEAUMONTSTATE: CAZIP CODE:
92223
CAPACITY:6CENSUS: 0DATE:
11/30/2022
ANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Licensee/Administrator Caroline ArmstrongTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Facility is not following fire safety protocols.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Melody Brown met with Licensee/Administrator Caroline Armstrong at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office 11/30/2022 at 10:30 AM to deliver the findings of the above allegation. LPA Brown explained the purpose of the requested Office Visit. The investigation consisted of observation, interviews and a review of pertinent documentation.

The investigation was conducted by LPA Brown. The investigation consisted of file review and interviews with relevant parties. The allegation indicated that Facility is not following fire safety protocols. Interview with City of Beaumont Fire Marshall staff indicated that the the door separating rooms 1 and 2 from the remainder of the living space was not permitted by the City of Beaumont Department of Building and Safety.
***Continuation on LIC9099C***
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 18-AS-20211012101603
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: ATIENZA RESIDENTIAL CARE
FACILITY NUMBER: 331880723
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/01/2022
Section Cited
CCR
87203
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87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by:
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Licensee stated to submit Signed Statement of Understanding on CCR 87203 to LPA Brown by POC due date.

Licensee stated to submit plan and timetable on how to bring the egress or secured perimeter arrangement into compliance and submit Signed Statement to LPA Brown by POC due date.
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Based on interview and records review, the Licensee did not comply with the section cited above by having a door that separates rooms 1 and 2 from the remainder of the living space without approval from the City of Beaumont Fire Marshall as it did not meet the egress or secured perimeter requirements per Fire Safety Inspection last 07/24/2019 which pose immediate health, safety, and personal rights risks to clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 18-AS-20211012101603
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: ATIENZA RESIDENTIAL CARE
FACILITY NUMBER: 331880723
VISIT DATE: 11/30/2022
NARRATIVE
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City of Beaumont Fire Marshall staff added that the door separating rooms 1 and 2 from the remainder of the living space did not meet their requirements as it needs to be solid wood door not less than 1 3/8" thick, maintained self-closing or automatic closing by actuation of a smoke detector, and shall positively latch upon closing. Moreover, City of Beaumont Fire Marshall staff indicated that the facility was not able to correct the egress or secured perimeter requirement since the fire safety inspection last 07/29/2019.

Based on LPA Brown’s observations and interviews, the preponderance of evidence standard has been met, therefore the allegation Facility is not following fire safety protocols is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 & Chapter 8) is being cited on the attached LIC9099D.

An exit interview was conducted where this report, LIC9099, LIC9099D, and Appeal Rights were discussed and provided to Administrator Caroline Armstrong.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/12/2021 and conducted by Evaluator Melody Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20211012101603

FACILITY NAME:ATIENZA RESIDENTIAL CAREFACILITY NUMBER:
331880723
ADMINISTRATOR:ARMSTRONG, CAROLINEFACILITY TYPE:
740
ADDRESS:1328 GALAXY DRTELEPHONE:
(909) 792-3835
CITY:BEAUMONTSTATE: CAZIP CODE:
92223
CAPACITY:6CENSUS: 0DATE:
11/30/2022
ANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrator Caroline ArmstrongTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Resident sustained multiple falls while in care.
Residents are locked in an area of the facility.
Resident sustained unexplained injury while in care.
Staff did not seek medical attention for resident in a timely manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Melody Brown met with Administrator Caroline Armstrong at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office 11/30/2022 at 10:30 AM to deliver the findings of the above allegations. LPA Brown explained the purpose of the requested Office Visit. The investigation consisted of observation, interviews and a review of pertinent documentation.

The investigation was conducted by LPA Brown. The investigation consisted of file review and interviews with relevant parties. The first allegation indicates resident sustained multiple falls while in care. Evidences show that R1 sustained multiple falls while living at the facility. However, evidences also show that the facility reported the falls to R1’s Hospice, ensured that R1 was medically assessed, and called 911 for lift assist as instructed by R1’s Hospice if needed.

***Continuation on LIC9099C***
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 18-AS-20211012101603
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: ATIENZA RESIDENTIAL CARE
FACILITY NUMBER: 331880723
VISIT DATE: 11/30/2022
NARRATIVE
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The second allegation indicates residents are locked in an area of the facility. Interviews with staff, Hospice Nurse and CALFIRE Beaumont staff revealed that residents are not locked in an area of the facility and no incidents occurred that they witnessed a resident locked in an area of the facility.

The third allegation indicates resident sustained unexplained injury while in care. Interviews and documents review revealed that R1 had an abrasion/skin tear on left hand due to R1's reported falls from getting up of bed with bedrail. S1 reported that they are reporting all incidents and falls to R1's Hospice and R1's medically assessed each time by the Hospice Nurse. LPA Brown reviewed Hospice Care Notes and LPA Brown observed that R1's left hand had an abrasion/skin tear was noted and reported due to R1's fall from getting up of bed with bedrail.

The fourth allegation indicates staff did not seek medical attention in a timely manner. Interviews and documents review revealed the facility's reporting all R1's incidents to R1's Hospice and either a Hospice Nurse will come out to the facility to medically assess R1 or the facility will call 911 if instructed by R1's Hospice. Hospice Nurse reported that the facility always report to them and they give instruction to facility staff of what to do and no incident occurred at the facility that staff did not seek medical attention for R1 in a timely manner. Also, LPA Brown reviewed Hospice Care notes and it indicated that during the incident last 10/10/2021, the Hospice staff did not advise the facility to call for non-emergency services and the facility waited for Hospice Nurse to medically assess R1.

Based on interviews and records review, the allegation resident sustained multiple falls while in care (Allegation #1), residents are locked in an area of the facility (Allegation #2), resident sustained unexplained injury while in care (Allegation #3), staff did not seek medical attention in a timely manner (Allegation #4) are UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

An exit interview was conducted, where this report (LIC9099) was discussed and provided to Administrator Caroline Armstrong.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5